=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447840863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY JOY BRADLEY LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2021
-----------------------------------------------------
Last Update Date | 01/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1853 R W BERENDS DR SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-466-8012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 SLAYTON AVE
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-638-0315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 4703099428
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------